1. 1. Initial Application for Authority to Self-Insure Form,
2. 2. Self-Insurance Renewal Application Form,
3. 3. New Pool Member Application Form,
4. 4. Workers’ Compensation Liability Form,
5. 5. Application to Self-Administer Form,
6. 6. Self-Provider of Medical Benefits Form,
7. 7. Parent Guaranty Form,
8. 8. Workers’ Compensation Guaranty Bond Form,
9. 9. Statutory Deposit Agreement Form,
10. 10. Custody Agreement Form,
11. 11. Request for Waiver of Security Form,
12. 12. Notice of Termination of Self-Insurance Form,
13. 13. Annual Payroll Report Form,
14. 14. Annual Medical Report Form,
15. 15. Annual Injury Report Form,
16. 16. Annual Hospital Report Form,
17. 17. Quarterly Tax Payment Form.

The following forms, available at http://www.azica.gov and upon request from the Division, shall be used when applicable:

Historical Note

New Section made by final rulemaking at 28 A.A.R. 3435 (October 28, 2022), with an immediate effective date of October 5, 2022 (Supp. 22-4).